[Mammography screening in the county of Copenhagen. Results of the first three screening rounds]

INTRODUCTION

Biennial service mammography screening for breast cancer has been offered to women aged 50-69 years in the municipality of Copenhagen since 1991. We report the results of the first three invitation rounds.

MATERIAL AND METHODS

Data were collected from the Copenhagen service mammography screening database and other Danish registers.

RESULTS

The average participation rate during the first three invitation rounds was 66%. The breast cancer detection rate was 10/1,000 screened in the first invitation round and 5/1,000 in the consecutive rounds. The probability of a false positive mammography was 6% at the prevalent screen, and this was reduced to 3% at incidence screens. Fifty-two cases of interval cancer were seen after the first invitation round. The expected number was 152, which gives a proportional interval cancer rate of 0.34. The sensitivity was 86% and the specificity 94% after the first round.

DISCUSSION

The detection rate of breast cancer was high, especially in the prevalence round. The trend in the incidence of breast cancer at the subsequent rounds was similar to that before screening, which indicates that mammography screening does not lead to any greater over-diagnosis. The rate of false positive mammography was high at the initial screening round, but was acceptable at subsequent rounds, and a false positive mammography does not seem to have affected participation in subsequent rounds. The Copenhagen screening programme conforms to international quality assurance guidelines for process evaluation.

State certification of mammography facilities. Final rule

The Food and Drug Administration (FDA) is amending its regulations governing mammography. The amendments implement the "States as Certifiers" (SAC) provisions of the Mammography Quality Standards Act of 1992 (MQSA). These amendments permit FDA to authorize individual States to certify mammography facilities, conduct facility inspections, enforce the MQSA quality standards, and administer other related functions. The amendments establish the standards to be met by States receiving this authority. They also establish procedures for application, approval, evaluation, and withdrawal of approval of States as certification agencies. FDA retains oversight responsibility for the activities of the States to which this authority is given. Mammography facilities certified by those States must continue to meet the quality standards established by FDA for mammography facilities nationwide.

Patient satisfaction with the communication of mammographic results before and after the Mammography Quality Standards Reauthorization Act of 1998

OBJECTIVE

The goal of this study was to evaluate the difference in patient satisfaction, timeliness of reporting, patient recollection of recommendations, and patient anxiety before and after passage of the Mammography Quality Standards Reauthorization Act of 1998, which requires written notification of all mammographic results.

MATERIALS AND METHODS

We used a telephone survey with sampling that was stratified to reflect patients with normal and abnormal findings who had screening and diagnostic mammograms. Patients with visits before the mandate became effective (April 1999, n = 298) and after (January 2000, n = 316) were interviewed about the average time to receive results, satisfaction with communication about results, anxiety, and perceived follow-up recommendations. Multiple logistic regression was used to test the association of time period with patient dissatisfaction, controlling for age, anxiety level (considerable or extreme vs none or moderate), examination type (screening vs diagnostic), and examination result (normal vs abnormal findings).

RESULTS

No significant difference was found between periods in anxiety about results or agreement with documented radiology recommendations, but we found a substantial increase in the number of screening patients who reported timely receipt of results. Significantly fewer patients were dissatisfied with mammographic results communication after the mandate (multivariable odds ratio = 0.46, p = 0.006). Screening examination patients and patients who reported considerable or extreme anxiety about test results were more likely to be dissatisfied in both periods.

CONCLUSION

By standardizing results notification, the Mammography Quality Standards Reauthorization Act improved patient satisfaction and reporting timeliness among screening examination patients, but did little to improve anxiety or recollection of recommendations. Future quality improvement efforts should focus on improving patients' understanding of follow-up recommendations.

Quality control of the physical and technical aspects of mammography in the Norwegian breast-screening programme

The aim of this study was to establish a system for quality control of technical and physical aspects of mammography in the national Norwegian breast-screening programme, and to evaluate test results obtained during the 4-year pilot project period. Quality control (QC) procedures for the X-ray unit, film and processing, cassettes and screens, view boxes, and image quality were described in two QC manuals. Frequent and relatively simple tests were performed by radiographers on-site and results reported semi-annually to an inspection group established at the Norwegian Radiation Protection Authority (NRPA). Tests requiring special equipment were performed prior to start of screening (first status controls), then annually by the NRPA group, which also assembled and analysed the data from the first 4 years. The analyses were done mainly with reference to stated standard or guidance levels and the degree of deviation from such values. Results for tests of i.a. focal spot size, exposure time, radiation output, mean absorbed glandular dose, reference optical density, sensitometry, and AEC performance are presented. The standard of the equipment tested was in general high. Although some deviations from optimal performance were seen throughout the project, the equipment mostly performed well within the stated limiting values.

[Quality assurance of mammographic devices]

An account of the technical features of mammographic devices as a consequence of the radiological requirements for imaging the breast is given. For quality assurance of these features specific test procedures have been established which at least since the introduction of the MED-directive 97/43 of CEC have to be applied. A concise summary of these protocols is given.

[Mammographic screening in the municipality of Copenhagen 1991-1997. Evaluation of the preoperative assessment]

INTRODUCTION

A biennial mammography screening programme started for all women aged 50-69 in the municipality of Copenhagen, Denmark, in April 1991. The aim of the present study was to evaluate the quality of the preoperative diagnostic assessment for women recalled for further examination. Quality indicators were: validity of the fine-needle aspiration cytology, rate of malignant to benign surgery, and frequency of one-step surgery for malignant lesions.

MATERIAL AND METHOD

Database registries during the first three screening rounds from April 1991 to March 1997 were studied retrospectively, for fine-needle aspiration cytology tests where surgical biopsy was also performed.

RESULTS

In the period 1991-1997, 4,111 women were recalled for clinical mammography and subsequently 1,086 women underwent surgery. The use of the triple test in the preoperative assessment increased from 50% in the first screening round to 72% in the third. Throughout the period of evaluation, the number of inadequate fine-needle aspiration cytology (FNAC) was reduced from 32% to 6%. Inadequate FNAC from malignant lesions declined from 27% to 6%. The sensitivity of FNAC increased from 67% to 90% and the accuracy from 60% to 81%. The malignant/benign ratio of surgery rose from 1.4 in the first screening round to 2.8 in the third. One-step surgery as definitive treatment was performed in 67% of malignant instances.

DISCUSSION

The preoperative diagnostic assessment improved during the evaluation period. The triple test was used more often over time, the validity of FNAC and the malignant/benign ratio of surgery increased.

Dangers and unreliability of mammography: breast examination is a safe, effective, and practical alternative

Mammography screening is a profit-driven technology posing risks compounded by unreliability. In striking contrast, annual clinical breast examination (CBE) by a trained health professional, together with monthly breast self-examination (BSE), is safe, at least as effective, and low in cost. International programs for training nurses how to perform CBE and teach BSE are critical and overdue.

Microdosimetric characterisation of 28 kVp Mo/Mo, Rh/Rh, Rh/Al, W/Rh and Mo/Rh mammography X ray spectra

Microdosimetric characteristics of 28 kVp mammography X ray spectra were studied for several target/added filtration combinations (Mo/Mo, Rh/Rh, Rh/Al, W/Rh, Mo/Rh). Monte Carlo techniques were used to model X ray production from mammography units and to calculate distributions of absorbed dose and energy imparted in breast tissue. The results show that the dose averaged lineal energy is about 5.0 keV.micron-1, about 25% higher than for general diagnostic imaging X ray spectra. Significant differences in lineal energy between the five X ray qualities were noted, with the highest value for the commonly used Mo/Mo combination. Spectral hardening with depth in the tissues causes a 5% decrease in lineal energy over 5 cm. No significant differences were found for the different tissue compositions.

Assessment of response by breast helical computed tomography to neoadjuvant chemotherapy in large inflammatory breast cancer

Breast helical computed tomography (CT) was evaluated for use in assessing response to neoadjuvant chemotherapy and residual tumor volume. Forty-three patients with large, inflammatory breast cancers (stage IIA, 12; IIB, 13; IIIA, 9; IIIB, 9), all histologically confirmed by core biopsy, were evaluated prior to and following neoadjuvant chemotherapy. The breast helical CT procedure involved patients in the prone position using single acquisition during quiet respiration following intravenous injection of nonionic contrast material. Helical CT results (3.2-mm slices and maximum intensity projections) were compared to clinical and mammographic evaluations, as well as to pathologic findings. All tumors were clearly visible by breast helical CT, showing important tumor enhancement. Helical CT evaluation of response to chemotherapy (using World Health Organization criteria) corresponded better with mammography (78%, Cohen's kappa statistic (kappa) = 0.65) than with clinical examination (53%, kappa = 0.30). Helical CT measurement of residual tumor volume after neoadjuvant chemotherapy and correlation with pathologic findings were globally satisfactory. The intraclass correlation coefficient was 0.69 (excellent for rounded opacities [0.97], but not as good for diffuse, scattered or multinodular opacities [0.60]). By contrast, clinical and mammographic correlations were globally unsatisfactory (0.49 and 0.28, respectively). Breast helical CT can be very useful in the quantitative assessment of response to neoadjuvant chemotherapy and preoperative determination of residual tumor volume. For this reason, it can be considered an alternative to breast magnetic resonance imaging because of its simplicity, rapidity, and accessibility.

[Development of computer technology for increasing the resolution of radiographic images in mammography]

A computer technology has been developed to enhance the resolution of an X-ray signal by 1.5-2 times than the baseline values. The results have been tested on real mammological X-ray films that are to detect minor inclusions, such as calcinates.

American Cancer Society guidelines for the early detection of cancer

Each year the American Cancer Society publishes a summary of existing recommendations for early cancer detection, including updates, and/or emerging issues that are relevant to screening for cancer. In last year's article, the guidelines regarding screening for the early detection of prostate, colorectal, and endometrial cancers were updated, as was the narrative pertaining to testing for early lung cancer detection. Although none of the ACS's guidelines were updated in 2001, work is proceeding on an update of screening recommendations for breast and cervical cancer and an update of these guidelines will be announced in the January/February 2003 issue of CA. As in previous issues, we review recommendations for the "cancer-related check-up," in which clinical encounters provide case-finding and health counseling opportunities. Finally, we provide an update of the most recent data pertaining to participation rates in cancer screening by age, gender, and ethnicity from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS) and National Health Interview Survey (NHIS).

An audit of screening for familial breast cancer before 50 years in the South Thames Region – have we got it right?

We have carried out an audit of breast screening by mammography under 50 years of age in a cohort of 192 women attending family cancer clinics run by the South Thames genetic services. Of these women, six came from families in which a BRCA mutation had been identified, 61 had > 50%, 35 a 20-50% and 90 had < 20% chance of carrying a high risk mutation. In the 192 women in the screened cohort, 9 breast cancers were diagnosed (4.7%), all in high-risk women. Three were diagnosed at the prevalence screen. Three were detected mammographically at subsequent screening rounds; three were detected by breast self-examination (BSE) between screening episodes. One interval cancer was visible on mammogram at presentation but not at screening five months previously. A second cancer was also visible on mammogram at presentation but the normal screening mammogram had been 17 months earlier, outside the recommended interval. The remaining interval cancer was not visible on the mammogram. A total of 363 two-view screening mammograms were performed in the 280 person-years of follow-up; 109 additional investigations were generated: 23 recall mammograms, 18 symptomatic mammograms, 45 ultrasounds, 12 aspiration cytologies and 11 biopsies. Cytology diagnosed malignancy in 1 of 12 cases; breast biopsy in 9 of 11 cases. Twenty-three additional women had ultrasound screening only. This audit suggests that screening below the age 50 years may be unnecessary in families with a low chance of having a BRCA1 or -2 mutation, but it is important to screen high-risk women at least annually and possibly under 35 years.

[Mortality of breast cancer and frequency of mammography in Hungary]

The Hungarian breast cancer mortality is above the European average. Because of the lack of effective primary prevention, the control has to be based on the improving results of treatment which is much more successful in the case of early detected cancers. Beyond the patients collaboration and the application of the recommended diagnostic protocols, the population based screening programs have high importance in achieving earlier diagnosis. This study aimed to describe the regional differences of mammography's application as an indicator of diagnostic and screening performance. The records of the outpatient services' reports containing the code for native X-ray examination of the breast were analysed in the period of 01/07/1998 to 30/04/2000. The age specific and the age standardised relative frequencies of mammographical examination were determined for the Hungarian counties and Budapest. The observed age specific frequency of mammography for the whole country was 17, 21, 11 and 4% for the age group of 40-49, 50-59, 60-69 and 70-74 years, respectively. The lowest observed values were 10 times smaller than the highest ones in every studied age group. The age standardised relative frequency of mammographical examination was higher than the national average in Tolna (2.52), Borsod-Abaúj-Zemplén (1.48), Zala (1.41), Baranya (1.33), and Csongrád (1.27) counties and in Budapest (1.35). The described data demonstrates that the Hungarian practice of mammography is far from acceptable considering the frequency of application. On the other hand, it was also explored that serious geographical differences exist within the country. It seems that there are providers that can achieve relative successes in diagnosing the breast cancers in as early stage as it is possible. The evaluation and utilisation of the experiences of these providers could increase the efficacy of interventions organised to improve the Hungarian epidemiological status of breast cancer.

Additional value of electrical impedance scanning: experience of 240 histologically-proven breast lesions

The aim of this study was to quantify the clinical value of using electrical impedance scanning (EIS) as an adjunct to other diagnostic techniques in order to identify cancerous tissue based upon its inherent altered local dielectric properties. 210 consecutive women with 240 sonographically and/or mammographically suspicious findings were examined using EIS. All lesions were histologically-proven. 86/103 malignant and 91/137 benign lesions were correctly identified using EIS (87.8% sensitivity, 66.4% specificity). NPV and PPV of 84.3% and 65.2% were observed, respectively. Excluding cases as defined by a priori criteria, i.e. lesions located deeper than 35 mm, lesions larger than 35 mm, and retroareolar lesions, a sensitivity of 85.5% was observed, and for invasive cancers, 91.7%. The detection rate for ductal carcinoma in situ (DCIS) was poor (57.1%, n=14). By adding EIS to mammography and ultrasound, the sensitivity rose from 86.4 to 95.1%, whereas the accuracy decreased from 82.3 to 75.7%. EIS appears to be of interest as an adjunct to breast diagnostic techniques, performing with a reasonable sensitivity. Further investigations on histomorphological characteristics and the reasons for false-negative findings are essential to gain further knowledge about the bioelectricity of breast lesions, and prove the value of this new technology.

Does the chronic care model serve also as a template for improving prevention?

Practical models of ways to enhance service delivery are sorely needed to help close the gap between research and practice. An evidenced-based model of chronic-illness management is shown to apply equally to preventive interventions. Successful examples of prevention programs in cancer screening and counseling for health behavior change illustrate the utility of the model for prevention and across different types of health care organizations. Although there are some important differences between interventions required for chronic disease management and prevention, there are a greater number of common factors. They share the need to alter reactive acute-care-oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required for both prevention and chronic care.

[Breast cancer screening lacking effectiveness]

The recent Cochrane review on mammographic breast cancer screening disclosed no convincing reduction of breast cancer mortality, together with an increase in the number of aggressive treatments. Given this outcome, there no longer exists solid experimental evidence to support mass screening. In the Netherlands over 800,000 women are invited to participate in this activity yearly. Is this still justifiable? The final answer rests on the conclusions from the analyses carried out from three different perspectives. From the methodological viewpoint, a broad re-analysis is needed which also takes the long-term adverse effects of radiotherapy into account. From the tumourbiological perspective, whether 'early' diagnosis really has potential therapeutic consequences should be explored further. From a societal perspective, more detailed and balanced information is required, since expectations regarding the effect of screening are unrealistic. Given the preliminary outcomes of these analyses, there are now serious reservations as to whether continuation of screening is justified. Women should be informed about this matter promptly.

Relationship between phantom failure rates and radiation dose in mammography accreditation

The American College of Radiology Mammography Accreditation Program (ACR MAP) reviews both clinical mammograms and a phantom image to assess clinical and technical quality from each mammography unit. The phantom contains details representing fibers (speculations), speck groups (microcalcifications), and masses. The depiction of these structures by the mammographic system is scored by medical physicists. The phantom image is taken using the facility's exposure technique for a 4.2-cm thick breast of average composition. The mean glandular dose (MGD) is determined from a set of thermoluminescent dosimeters placed on top of the chest wall edge of the phantom. Phantom scores and MGD data collected from 1993 to 1999 based on 31 535 unit evaluations are presented in this paper. The relationship between the failure rate for phantom image quality and MGD has been analyzed. While over all doses the phantom failure rate was 11%, for doses of 0.26 to 0.50 mGy the failure rate was 43%. The phantom failure rate fell continuously to about 6% for MGDs in the range of 1.51-2.0 mGy. With further increases in dose, failure rates began to rise. Factors that may account for these results are presented and discussed.